Minimally Detectable Change and Minimal Clinically Important Difference of a Decline in Sentence Intelligibility and Speaking Rate for Individuals With Amyotrophic Lateral Sclerosis

Operationalizing Clinical Speech Analytics: Moving From Features to Measures for Real-World Clinical Impact

OBJECTIVE

This research note advocates for a methodological shift in clinical speech analytics, emphasizing the transition from high-dimensional speech feature representations to clinically validated speech measures designed to operationalize clinically relevant constructs of interest. The aim is to enhance model generalizability and clinical applicability in real-world settings.

METHOD

We outline the challenges of using conventional supervised machine learning models in clinical speech analytics, particularly their limited generalizability and interpretability. We propose a new framework focusing on speech measures that are closely tied to specific speech constructs and have undergone rigorous validation. This research note discusses a case study involving the development of a measure for articulatory precision in amyotrophic lateral sclerosis (ALS), detailing the process from ideation through Food and Drug Administration (FDA) breakthrough status designation.

RESULTS

The case study demonstrates how the operationalization of the articulatory precision construct into a quantifiable measure yields robust, clinically meaningful results. The measure's validation followed the V3 framework (verification, analytical validation, and clinical validation), showing high correlation with clinical status and speech intelligibility. The practical application of these measures is exemplified in a clinical trial and designation by the FDA as a breakthrough status device, underscoring their real-world impact.

CONCLUSIONS

Transitioning from speech features to speech measures offers a more targeted approach for developing speech analytics tools in clinical settings. This shift ensures that models are not only technically sound but also clinically relevant and interpretable, thereby bridging the gap between laboratory research and practical health care applications. We encourage further exploration and adoption of this approach for developing interpretable speech representations tailored to specific clinical needs.

No differential effects of subthalamic nucleus vs. globus pallidus deep brain stimulation in Parkinson's disease: Speech acoustic and perceptual findings

Background

Deep Brain Stimulation (DBS) in the Subthalamic Nucleus (STN) or the Globus Pallidus Interna (GPI) is well-established as a surgical technique for improving global motor function in patients with idiopathic Parkinson's Disease (PD). Previous research has indicated speech deterioration in more than 30% of patients after STN-DBS implantation, whilst speech outcomes following GPI-DBS have received far less attention. Research comparing speech outcomes for patients with PD receiving STN-DBS and GPI-DBS can inform pre-surgical counseling and assist with clinician and patient decision-making when considering the neural targets selected for DBS-implantation. The aims of this pilot study were (1) to compare perceptual and acoustic speech outcomes for a group of patients with PD receiving bilateral DBS in the STN or the GPI with DBS stimulation both ON and OFF, and (2) examine associations between acoustic and perceptual speech measures and clinical characteristics.

Methods

Ten individuals with PD receiving STN-DBS and eight individuals receiving GPI-DBS were audio-recorded reading a passage. Three listeners blinded to neural target and stimulation condition provided perceptual judgments of intelligibility and overall speech severity. Speech acoustic measures were obtained from the recordings. Acoustic and perceptual measures and clinical characteristics were compared for the two neural targets and stimulation conditions.

Results

Intelligibility and speech severity were not significantly different across neural target or stimulation conditions. Generally, acoustic measures were also not statistically different for the two neural targets or stimulation conditions. Acoustic measures reflecting more varied speech prosody were associated with improved intelligibility and lessened severity. Convergent correlations were found between UPDRS-III speech scores and perceptual measures of intelligibility and severity.

Conclusion

This study reports a systematic comparison of perceptual and acoustic speech outcomes following STN-DBS and GPI-DBS. Statistically significant differences in acoustic measures for the two neural targets were small in magnitude and did not yield group differences in perceptual measures. The absence of robust differences in speech outcomes for the two neural targets has implications for pre-surgical counseling. Results provide preliminary support for reliance on considerations other than speech when selecting the target for DBS in patients with PD.

Co-constructed communication therapy for individuals with acquired brain injury: A systematic review

BACKGROUND

Meaningful, varied, joyful conversation is an important therapy target for adults with language or cognitive-communication disorders following acquired brain injury (ABI). However, the complexity of daily communication is often reduced to component parts within intervention programmes, with mixed evidence of generalization to everyday conversation. Interventions targeting co-construction of communication within a dyad offer a structured way in which to retain and treat elements of everyday conversation for individuals and their communication partner (CP). Such interventions exist but they are variably labelled, target different ABI populations and have not been synthesized.

AIMS

To identify the nature, scope and effects of intervention studies targeting co-constructed communication in adults with ABI.

METHOD

This systematic review was completed using PRISMA Guidelines. Six databases (MEDLINE, Embase, CINAHL, Scopus, LLBA, PsychInfo) were searched and 1210 studies were screened. Data were extracted and studies were rated for methodological quality and completeness of reporting. Outcome measures and effects of treatment were collated through descriptive synthesis.

MAIN CONTRIBUTION

This review highlights an emerging evidence base in relation to an intervention approach that targets everyday communication. Co-constructed communication interventions have been reported by 13 studies, from a total of 206 participants with post-stroke aphasia, traumatic brain injury and progressive language impairments. These interventions take a range of formats, including referential communication tasks, retell/recount therapies and communication training programmes. Methodological quality evaluation indicated mostly low-level study designs. Heterogeneity was identified in primary outcome measures, with 28 unique primary outcome measures reported across studies. Most studies demonstrated change in task-specific or broad communication outcome measures.

CONCLUSIONS

Co-constructed communication interventions may offer clinicians a systematic, protocolized, replicable way to target everyday communication for adults with ABI. More high-quality, experimental designs with complete reporting and psychometrically sound outcome measures are needed to strengthen the evidence base.

WHAT THIS PAPER ADDS

What is already known on this subject Everyday conversation is an important therapy target for adults with ABI, but there is mixed evidence of therapy gains generalizing to everyday life. Many interventions reduce conversation to component parts such as naming or sentence construction. A different approach is needed to capture the social, dyadic, interactive and multifaceted nature of conversation. We propose the term 'co-constructed communication interventions' as a therapy genre targeting semi-structured dialogue. These interventions retain elements of everyday conversation (such as multimodal communication and situating tasks within dyads), combined with experimental elements (where stimuli prompt interactions and responses can be scored against normative data). What this paper adds to existing knowledge This review proposes and describes a distinct genre of discourse intervention within the current evidence base with a novel operational definition of 'co-constructed communication'. What are the potential or actual clinical implications of this work? Co-constructed communication interventions directly target elements of everyday communication by situating the therapy goals within a dyadic, interactive, multimodal task. A range of intervention tasks have been identified, including collaborative storytelling and problem-solving. This review will be of interest to clinicians working with adults with ABI; co-constructed communication interventions may offer a useful, replicable way to target aspects of everyday communication. This synthesis of the current evidence base encourages clinicians' informed, evidence-based decisions around these interventions.

Reliability and validity of the Turkish version of the patellofemoral pain severity scale in patients with patellofemoral pain syndrome

PURPOSE

The aim of this study was to investigate the Turkish validity and reliability of the Patellofemoral Pain Severity Scale (PSS) in patients with patellofemoral pain (PFP) and to adapt it to Turkish.

MATERIALS AND METHODS

A pilot study was conducted with 10 patients. 123 patients underwent PSS test-retest at 24-48 h intervals. Construct validity, correlations of PSS with other scales Timed Up and Go Test (TUG), Stair Climbing and Descending Test (SCD), Anterior Knee Pain Scale (AKPS), Tegner Activity Scale (TAS), Lysholm Knee Scoring Scale (LDSS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL) were evaluated.

RESULTS

The content validity index value of the scale was 0.95. The overall internal consistency (Cronbach α: 0.88) was high. Item-total correlations of the scale were between 0.51 and 0.7. In the evaluation of the convergent validity of the PSS, it was found that there was a positive correlation between the PSSS and TUG and SCD, and a negative correlation between the PSS, TAS, LDSS and KOS-ADL (p = 0.000).

CONCLUSIONS

In this study, it was determined that the PSSS scale had good internal consistency, test-retest validity and adequate construct validity when compared with the KOS-ADL, LDSS and AKPS.

Minimum Clinically Important Difference (MCID) and Patient Acceptable Symptomatic State (PASS) Applied to the SF-36 in Patients Who Underwent Arthroscopic Rotator Cuff Repair

The 36-Item Short-Form Health Survey questionnaire (SF-36) is a reliable tool to assess the health-related quality of life of patients. If a mean difference between pre-operative evaluation and final follow-up is found to be statistically significant, then the change in score is not random. However, a statistically significant mean change may not correspond to a clinical amelioration for the patient or mean that the patient's state of health is to be considered acceptable. For this reason, interest in the concepts of minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) has grown within recent years. The goal of the present work of research was to determine the MCID and PASS values for the SF-36 in patients who received rotator cuff repair (RCR). Forty-six patients (18 women and 28 men, mean age 58.5 ± 12.9) previously diagnosed with rotator cuff disease were enrolled. All of these patients underwent RCR. They were evaluated pre-operatively and six months after the surgical intervention as a final follow-up. The SF-36 questionnaire was assessed at each evaluation. The MCID cut-offs of the total, physical, and mental dimensions of the SF-36 for patients who underwent RCR were 23.1, 32.5, and 18.1, respectively. A 23.1 improvement in the SF-36 score at six months following RCR can be correlated with patients having reached a clinically significant improvement in health status. If 81.9 or more is attained in the SF-36 score after surgical repair, the symptom state can be judged as satisfactory by the majority of patients.

Improving Perceptual Speech Ratings: The Effects of Auditory Training on Judgments of Dysarthric Speech

PURPOSE

Auditory training has been shown to reduce rater variability in perceptual voice assessment. Because rater variability is also a central issue in the auditory-perceptual assessment of dysarthria, this study sought to determine if training produces a meaningful change in rater reliability, criterion validity, and scaling magnitude of four features: overall speech impairment, articulatory imprecision, monotony, and slow rate.

METHOD

Forty-four nonexperts randomized to training and nontraining listener groups completed a pretest and posttest. Only the former group underwent auditory training between pre- and posttests. For both testing and training, listeners rated samples from speakers with amyotrophic lateral sclerosis (ALS), speakers with Parkinson's disease (PD), and neurologically healthy control speakers using separate visual analog scales (VASs) for each of the four features. Intraclass correlation coefficients were used to compare inter- and intrarater reliability between pre- and posttest for both listener groups. For criterion validity, severity ratings from the two nonexpert listener groups were compared to those of two experienced listeners for all four features. To determine changes in scaling magnitude, raw VAS scores for each feature were compared from pre- to posttest within the two nonexpert listener groups. Scaling changes were also compared between the two listener groups for the pre- and posttest conditions.

RESULTS AND CONCLUSIONS

In the training group, a meaningful improvement in interrater reliability was observed for some features in all three speaker groups, but not in the nontraining group. In contrast, for intrarater reliability, in the nontraining group, a meaningful improvement was observed for many features in all three speaker groups, but only for PD monotony and slow rate in the training group. All ratings from the nonexpert listeners were valid except for monotony. Raw VAS scores did not meaningfully change from pre- to posttest for any of the features, but there was a trend toward lower scores posttraining, mainly for the ALS samples. Modifications to the auditory training paradigm to further improve reliability and validity, along with future goals for optimizing training, are discussed.

Wav2DDK: Analytical and Clinical Validation of an Automated Diadochokinetic Rate Estimation Algorithm on Remotely Collected Speech

PURPOSE

Oral diadochokinesis is a useful task in assessment of speech motor function in the context of neurological disease. Remote collection of speech tasks provides a convenient alternative to in-clinic visits, but scoring these assessments can be a laborious process for clinicians. This work describes Wav2DDK, an automated algorithm for estimating the diadochokinetic (DDK) rate on remotely collected audio from healthy participants and participants with amyotrophic lateral sclerosis (ALS).

METHOD

Wav2DDK was developed using a corpus of 970 DDK assessments from healthy and ALS speakers where ground truth DDK rates were provided manually by trained annotators. The clinical utility of the algorithm was demonstrated on a corpus of 7,919 assessments collected longitudinally from 26 healthy controls and 82 ALS speakers. Corpora were collected via the participants' own mobile device, and instructions for speech elicitation were provided via a mobile app. DDK rate was estimated by parsing the character transcript from a deep neural network transformer acoustic model trained on healthy and ALS speech.

RESULTS

Algorithm estimated DDK rates are highly accurate, achieving .98 correlation with manual annotation, and an average error of only 0.071 syllables per second. The rate exactly matched ground truth for 83% of files and was within 0.5 syllables per second for 95% of files. Estimated rates achieve a high test-retest reliability (r = .95) and show good correlation with the revised ALS functional rating scale speech subscore (r = .67).

CONCLUSION

We demonstrate a system for automated DDK estimation that increases efficiency of calculation beyond manual annotation. Thorough analytical and clinical validation demonstrates that the algorithm is not only highly accurate, but also provides a convenient, clinically relevant metric for tracking longitudinal decline in ALS, serving to promote participation and diversity of participants in clinical research.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23787033.

Measuring Articulatory Patterns in Amyotrophic Lateral Sclerosis Using a Data-Driven Articulatory Consonant Distinctiveness Space Approach

PURPOSE

The aim of this study was to leverage data-driven approaches, including a novel articulatory consonant distinctiveness space (ACDS) approach, to better understand speech motor control in amyotrophic lateral sclerosis (ALS).

METHOD

Electromagnetic articulography was used to record tongue and lip movement data during the production of 10 consonants from healthy controls (n = 15) and individuals with ALS (n = 47). To assess phoneme distinctness, speech data were analyzed using two classification algorithms, Procrustes matching (PM) and support vector machine (SVM), and the area/volume of the ACDS. Pearson's correlation coefficient was used to examine the relationship between bulbar impairment and the ACDS. Analysis of variance was used to examine the effects of bulbar impairment on consonant distinctiveness and consonant classification accuracies in clinical subgroups.

RESULTS

There was a significant relationship between the ACDS and intelligible speaking rate (area, p = .003; volume, p = .010), and the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) bulbar subscore (area, p = .009; volume, p = .027). Consonant classification performance followed a consistent pattern with bulbar severity, where consonants produced by speakers with more severe ALS were classified less accurately (SVM = 75.27%; PM = 74.54%) than the healthy, asymptomatic, and mild-moderate groups. In severe ALS, area of the ACDS was significantly condensed compared to both asymptomatic (p = .004) and mild-moderate (p = .013) groups. There was no statistically significant difference in area between the severe ALS group and healthy speakers (p = .292).

CONCLUSIONS

Our comprehensive approach is sensitive to early oromotor changes in response due to disease progression. The preserved articulatory consonant space may capture the use of compensatory adaptations to counteract influences of neurodegeneration.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22044320.

Lexical Characteristics of the Speech Intelligibility Test: Effects on Transcription Intelligibility for Speakers With Multiple Sclerosis and Parkinson's Disease

PURPOSE

Lexical characteristics of speech stimuli can significantly impact intelligibility. However, lexical characteristics of the widely used Speech Intelligibility Test (SIT) are unknown. We aimed to (a) define variation in neighborhood density, word frequency, grammatical word class, and type-token ratio across a large corpus of SIT sentences and tests and (b) determine the relationship of lexical characteristics to speech intelligibility in speakers with multiple sclerosis (MS), Parkinson's disease (PD), and neurologically healthy controls.

METHOD

Using an extant database of 92 speakers (32 controls, 30 speakers with MS, and 30 speakers with PD), percent correct intelligibility scores were obtained for the SIT. Neighborhood density, word frequency, word class, and type-token ratio were calculated and summed for each of the 11 sentences of each SIT test. The distribution of each characteristic across SIT sentences and tests was examined. Linear mixed-effects models were performed to assess the relationship between intelligibility and the lexical characteristics.

RESULTS

There was large variability in the distribution of lexical characteristics across this large corpus of SIT sentences and tests. Modeling revealed a relationship between intelligibility and the lexical characteristics, with word frequency and word class significantly contributing to the model.

CONCLUSIONS

Three primary findings emerged: (a) There was considerable variability in lexical characteristics both within and across the large corpus of SIT tests; (b) there was not a robust association between intelligibility and the lexical characteristics; and (c) findings from a study demonstrating an effect of neighborhood density and word frequency on intelligibility were replicated. Clinical and research implications of the findings are discussed, and three exemplar SIT tests systematically controlling for neighborhood density and word frequency are provided.

Oromotor Nonverbal Performance and Speech Motor Control: Theory and Review of Empirical Evidence

This position paper offers a perspective on the long-standing debate concerning the role of oromotor, nonverbal gestures in understanding typical and disordered speech motor control secondary to neurological disease. Oromotor nonverbal tasks are employed routinely in clinical and research settings, but a coherent rationale for their use is needed. The use of oromotor nonverbal performance to diagnose disease or dysarthria type, versus specific aspects of speech production deficits that contribute to loss of speech intelligibility, is argued to be an important part of the debate. Framing these issues are two models of speech motor control, the Integrative Model (IM) and Task-Dependent Model (TDM), which yield contrasting predictions of the relationship between oromotor nonverbal performance and speech motor control. Theoretical and empirical literature on task specificity in limb, hand, and eye motor control is reviewed to demonstrate its relevance to speech motor control. The IM rejects task specificity in speech motor control, whereas the TDM is defined by it. The theoretical claim of the IM proponents that the TDM requires a special, dedicated neural mechanism for speech production is rejected. Based on theoretical and empirical information, the utility of oromotor nonverbal tasks as a window into speech motor control is questionable.

Establishing the Minimum Clinically Significant Difference (MCID) and the Patient Acceptable Symptom Score (PASS) for the Hospital Anxiety and Depression Scale (HADS) in Patients with Rotator Cuff Disease and Shoulder Prosthesis

Insufficiently treated shoulder pain may cause mental disturbances, including depression and anxiety. The Hospital Anxiety and Depression Scale (HADS) is a patient-reported outcome measure (PROM) that aims to identify depression and anxiety in patients in nonpsychiatric wards. The aim of this study was to identify the minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) scores for the HADS in a cohort of individuals with rotator cuff disease. Using the HADS, participants' degrees of anxiety and depression were assessed at inception and at their final assessment 6 months after surgery. To calculate the MCID and the PASS, distribution and anchor approaches were employed. The MCID from inception to final assessment was 5.7 on the HADS, 3.8 on the HADS-A, and 3.3 on the HADS-D. A 5.7 amelioration on the HADS score, 3.8 on the HADS-A, and 3.3 on the HADS-D, from inception to final assessment, meant that patients had reached a clinically meaningful improvement in their symptom state. The PASS was 7 on the HADS, 3.5 on the HADS-A, and 3.5 on the HADS-D; therefore, for the majority of patients, a score of at least 7 on the HADS, 3.5 on the HADS-A, and 3.5 on the HADS-D at final evaluation was considered a satisfactory symptom state.

Profiles of Dysarthria and Dysphagia in Individuals With Amyotrophic Lateral Sclerosis

PURPOSE

While dysarthria and dysphagia are known bulbar manifestations of amyotrophic lateral sclerosis (ALS), the relative prevalence of speech and swallowing impairments and whether these bulbar symptoms emerge at the same time point or progress at similar rates is not yet clear. We, therefore, sought to determine the relative prevalence of speech and swallowing impairments in a cohort of individuals with ALS and to determine the impact of disease duration, severity, and onset type on bulbar impairments.

METHOD

Eighty-eight individuals with a confirmed diagnosis of ALS completed the ALS Functional Rating Scale-Revised (ALSFRS-R), underwent videofluoroscopy (VF), and completed the Sentence Intelligibility Test (SIT) during a single visit. Demographic variables including disease duration and onset type were also obtained from participants. Duplicate, independent, and blinded ratings were completed using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale and SIT to index dysphagia (DIGEST ≥ 1) and dysarthria (< 96% intelligible and/or < 150 words per minute) status. Descriptive statistics, Pearson chi-squared tests, independent-samples t tests, and odds ratios were performed.

RESULTS

Dysphagia and dysarthria were instrumentally confirmed in 68% and 78% of individuals with ALS, respectively. Dysarthria and dysphagia were associated (p = .01), and bulbar impairment profile distributions in rank order included (a) dysphagia - dysarthria (59%, n = 52), (b) no dysphagia - dysarthria (19%, n = 17), (c) no dysphagia - no dysarthria (13%, n = 11), and (d) dysphagia - no dysarthria (9%, n = 8). Participants with dysphagia or dysarthria demonstrated 4.2 higher odds of exhibiting a bulbar impairment in the other domain than participants with normal speech and swallowing (95% CI [1.5, 12.2]). There were no differences in ALSFRS-R total scores or disease duration across bulbar impairment profiles (p > .05). ALSFRS-R bulbar subscale scores were significantly lower in individuals with dysphagia versus no dysphagia (8.4 vs. 10.4, p < .0001) and dysarthria versus no dysarthria (8.5 vs. 10.9, p < .0001). Dysphagia and onset type (p = .003) and dysarthria and onset type were associated (p < .0001).

CONCLUSIONS

Over half of the individuals with ALS in this study demonstrated both dysphagia and dysarthria. Of those with only one bulbar impairment, speech was twice as likely to be the first bulbar symptom to degrade. Future studies are needed to confirm these findings and determine the longitudinal progression of bulbar impairments in this patient population.

Effects of a Single Electrical Stimulation Session on Foot Force Production, Foot Dome Stability, and Dynamic Postural Control

CONTEXT

Mounting evidence suggests neuromuscular electrical stimulation (NMES) as a promising modality for enhancing lower limb muscle strength, yet the functional effects of a single electrical stimulation session for improving the function of the intrinsic foot muscles (IFM) has not been evaluated.

OBJECTIVE

To investigate the immediate effects of an NMES session compared with a sham stimulation session on foot force production, foot dome stability, and dynamic postural control in participants with static foot pronation.

DESIGN

Randomized controlled clinical trial.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 46 participants (23 males, 23 females) with static foot pronation according to their Foot Posture Index (score ≥ 6) were randomly assigned to an NMES (n = 23) or control (n = 23) group.

INTERVENTION(S)

The NMES group received a single 15-minute NMES session on the dominant foot across the IFM. The control group received a 15-minute sham electrical stimulation session.

MAIN OUTCOME MEASURE(S)

All outcome measurements were assessed before and after the intervention and consisted of foot force production on a pressure platform, foot dome stability, and dynamic postural control. Statistical analysis was based on the responsiveness of the outcome measures and responder analysis using the minimum detectable change scores for each outcome measure.

RESULTS

In the NMES group, 78% of participants were classified as responders for at least 2 of the 3 outcomes, compared with only 22% in the control group. The relative risk of being a responder in the NMES group compared with the control group was 3.6 (95% CI = 1.6, 8.1]. Interestingly, we found that all participants who concomitantly responded to foot strength and navicular drop (n = 8) were also responders in dynamic postural control.

CONCLUSIONS

Compared with a sham stimulation session, a single NMES session was effective in immediately improving foot function and dynamic postural control in participants with static foot pronation. These findings support the role of NMES for improving IFM function in this population.

Video-Based Facial Movement Analysis in the Assessment of Bulbar Amyotrophic Lateral Sclerosis: Clinical Validation

PURPOSE

Facial movement analysis during facial gestures and speech provides clinically useful information for assessing bulbar amyotrophic lateral sclerosis (ALS). However, current kinematic methods have limited clinical application due to the equipment costs. Recent advancements in consumer-grade hardware and machine/deep learning made it possible to estimate facial movements from videos. This study aimed to establish the clinical validity of a video-based facial analysis for disease staging classification and estimation of clinical scores.

METHOD

Fifteen individuals with ALS and 11 controls participated in this study. Participants with ALS were stratified into early and late bulbar ALS groups based on their speaking rate. Participants were recorded with a three-dimensional (3D) camera (color + depth) while repeating a simple sentence 10 times. The lips and jaw movements were estimated, and features related to sentence duration and facial movements were used to train a machine learning model for multiclass classification and to predict the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) bulbar subscore and speaking rate.

RESULTS

The classification model successfully separated healthy controls, the early ALS group, and the late ALS group with an overall accuracy of 96.1%. Video-based features demonstrated a high ability to estimate the speaking rate (adjusted R ² = .82) and a moderate ability to predict the ALSFRS-R bulbar subscore (adjusted R ² = .55).

CONCLUSIONS

The proposed approach based on a 3D camera and machine learning algorithms represents an easy-to-use and inexpensive system that can be included as part of a clinical assessment of bulbar ALS to integrate facial movement analysis with other clinical data seamlessly.

Acoustic and Kinematic Assessment of Motor Speech Impairment in Patients With Suspected Four-Repeat Tauopathies

PURPOSE

The aim of this study was to use acoustic and kinematic speech measures to characterize type of motor speech impairment-apraxia of speech (AOS) versus dysarthria-in individuals with four-repeat tauopathy (4RT)-associated syndromes, including nonfluent variant primary progressive aphasia (nfvPPA), primary progressive AOS (PPAOS), corticobasal syndrome (CBS), and progressive supranuclear palsy syndrome (PSPs).

METHOD

Twenty patient participants were recruited and stratified into two groups: (a) a motor-speech-impaired group of individuals with nfvPPA, PPAOS, CBS, or PSPs and suspected 4RT pathology ("MSI+") and (b) a non-motor-speech-impaired group of individuals with logopenic variant primary progressive aphasia ("MSI-"). Ten healthy, age-matched controls also participated in the study. Participants completed a battery of speech tasks, and 15 acoustic and kinematic speech measures were derived. Quantitative speech measures were grouped into feature categories ("AOS features," "dysarthria features," "shared features"). In addition to quantitative speech measures, two certified speech-language pathologists made independent, blinded auditory-perceptual ratings of motor speech impairment. A principal component analysis (PCA) was conducted to investigate the relative contributions of quantitative features.

RESULTS

Quantitative speech measures were generally concordant with independent clinician ratings of motor speech impairment severity. Hypothesis-driven groupings of quantitative measures differentiated predominantly apraxic from predominantly dysarthric presentations within the MSI+ group. PCA results provided additional evidence for differential profiles of motor speech impairment in the MSI+ group; heterogeneity across individuals is explained in large part by varying levels of overall severity-captured by the shared feature variable group-and degree of apraxia severity, as measured by the AOS feature variable group.

CONCLUSIONS

Quantitative features reveal heterogeneity of MSI in the 4RT group in terms of both overall severity and subtype of MSI. Results suggest the potential for acoustic and kinematic speech assessment methods to inform characterization of motor speech impairment in 4RT-associated syndromes.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21401778.

Clear Speech Variants: An Investigation of Intelligibility and Speaker Effort in Speakers With Parkinson's Disease

PURPOSE

This study investigated the effects of three clear speech variants on sentence intelligibility and speaking effort for speakers with Parkinson's disease (PD) and age- and sex-matched neurologically healthy controls.

METHOD

Fourteen speakers with PD and 14 neurologically healthy speakers participated. Each speaker was recorded reading 18 sentences from the Speech Intelligibility Test in their habitual speaking style and for three clear speech variants: clear (SC; given instructions to speak clearly), hearing impaired (HI; given instructions to speak with someone with a hearing impairment), and overenunciate (OE; given instructions to overenunciate each word). Speakers rated the amount of physical and mental effort exerted during each speaking condition using visual analog scales (averaged to yield a metric of overall speaking effort). Sentence productions were orthographically transcribed by 50 naive listeners. Linear mixed-effects models were used to compare intelligibility and speaking effort across the clear speech variants.

RESULTS

Intelligibility was reduced for the PD group in comparison to the control group only in the habitual condition. All clear speech variants significantly improved intelligibility above habitual levels for the PD group, with OE maximizing intelligibility, followed by the SC and HI conditions. Both groups rated speaking effort to be significantly higher for both the OE and HI conditions versus the SC and habitual conditions.

DISCUSSION

For speakers with PD, all clear speech variants increased intelligibility to a level comparable to that of healthy controls. All clear speech variants were also associated with higher levels of speaking effort than habitual speech for the speakers with PD. Clinically, findings suggest that clear speech training programs consider using the instruction "overenunciate" for maximizing intelligibility. Future research is needed to identify if high levels of speaking effort elicited by the clear speech variants affect long-term sustainability of the intelligibility benefit.

Articulatory Underpinnings of Reduced Acoustic-Phonetic Contrasts in Individuals With Amyotrophic Lateral Sclerosis

PURPOSE

The aim of this study is to identify the articulatory underpinnings of the acoustic-phonetic correlates of functional speech decline in individuals with amyotrophic lateral sclerosis (ALS).

METHOD

Thirteen individuals with varying severities of speech impairment secondary to ALS and 10 neurologically healthy controls speakers read 12 minimal word pairs, targeting the contrasts in the height, advancement, and length of vowels; the manner and place of articulation for consonants and consonant cluster; and liquid and glide approximants, 5 times. Sixteen acoustic features were extracted to characterize the phonetic contrasts of these minimal word pairs. These acoustic features were correlated with a functional speech index-intelligible speaking rate-using penalized regression, based on which the contributive features were identified as the acoustic-phonetic correlates of the functional speech outcome. Articulatory contrasts of the minimal word pairs were characterized by a set of dissimilarity indices derived by the dynamic time warping algorithm, which measured the differences in the displacement and velocity trajectories of tongue tip, tongue dorsum, lower lip, and jaw between the minimal word pairs. The contributive articulatory features to the acoustic-phonetic correlates were identified by penalized regression.

RESULTS

A variety of acoustic-phonetic features were identified as contributing to the functional speech outcome, of which the contrasts in vowel height and advancement, [r]-[l], [r]-[w], and initial cluster-singleton were the most affected in individuals with ALS. Differential articulatory underpinnings were identified for these acoustic-phonetic features. Impairments of these articulatory underpinnings, especially of tongue tip and tongue dorsum velocities and tongue tip displacement, were associated with reduced acoustic-phonetic contrasts of the minimal word pairs, in a context-specific manner.

CONCLUSION

The findings established explanatory relationships between articulatory impairment and the acoustic-phonetic profile of functional speech decline in ALS, providing useful information for developing targeted management strategies to improve and prolong functional speech in individuals with ALS.

Validity of Off-the-Shelf Automatic Speech Recognition for Assessing Speech Intelligibility and Speech Severity in Speakers With Amyotrophic Lateral Sclerosis

PURPOSE

There is increasing interest in using automatic speech recognition (ASR) systems to evaluate impairment severity or speech intelligibility in speakers with dysarthria. We assessed the clinical validity of one currently available off-the-shelf (OTS) ASR system (i.e., a Google Cloud ASR API) for indexing sentence-level speech intelligibility and impairment severity in individuals with amyotrophic lateral sclerosis (ALS), and we provided guidance for potential users of such systems in research and clinic.

METHOD

Using speech samples collected from 52 individuals with ALS and 20 healthy control speakers, we compared word recognition rate (WRR) from the commercially available Google Cloud ASR API (Machine WRR) to clinician-provided judgments of impairment severity, as well as sentence intelligibility (Human WRR). We assessed the internal reliability of Machine and Human WRR by comparing the standard deviation of WRR across sentences to the minimally detectable change (MDC), a clinical benchmark that indicates whether results are within measurement error. We also evaluated Machine and Human WRR diagnostic accuracy for classifying speakers into clinically established categories.

RESULTS

Human WRR achieved better accuracy than Machine WRR when indexing speech severity, and, although related, Human and Machine WRR were not strongly correlated. When the speech signal was mixed with noise (noise-augmented ASR) to reduce a ceiling effect, Machine WRR performance improved. Internal reliability metrics were worse for Machine than Human WRR, particularly for typical and mildly impaired severity groups, although sentence length significantly impacted both Machine and Human WRRs.

CONCLUSIONS

Results indicated that the OTS ASR system was inadequate for early detection of speech impairment and grading overall speech severity. While Machine and Human WRR were correlated, ASR should not be used as a one-to-one proxy for transcription speech intelligibility or clinician severity ratings. Overall, findings suggested that the tested OTS ASR system, Google Cloud ASR, has limited utility for grading clinical speech impairment in speakers with ALS.

Minimally Detectable Change of Speech Intelligibility in Speakers With Multiple Sclerosis and Parkinson's Disease

PURPOSE

This study sought to determine the minimally detectable change (MDC) of sentence intelligibility for speakers with multiple sclerosis (MS) and Parkinson's disease (PD).

METHOD

Speakers included 78 participants consisting of 32 neurologically healthy control speakers, 30 speakers with MS, and 16 speakers with PD. All speakers were recorded reading 11 sentences comprising the Speech Intelligibility Test (SIT), which were subsequently transcribed by inexperienced listeners. Percent correct scores were calculated for each sentence. An average percent correct score was also calculated for each speaker. The MDC at the 95% confidence interval was calculated using the following formula: MDC₉₅ = 1.96 × √2 × standard error of measurement. Speakers were divided into operationally defined categories of severity, and MDCs were calculated for each category to permit comparison to MDCs reported for speakers with amyotrophic lateral sclerosis (ALS). Kruskal-Wallis tests were conducted to compare MDCs between groups and severity categories.

RESULTS

The average MDC₉₅ for control speakers was 5.53% (range = 3.21%-7.47%) and was statistically smaller than MDCs for speakers with MS (average = 10.08%, range = 5.30%-15.62%) and those for speakers with PD (average = 10.98%, range = 8.60%-13.98%). Statistical analyses further revealed significant differences between MDCs across severity categories.

CONCLUSIONS

In agreement with previous work in ALS conducted under similar conditions (i.e., orthographic transcription of SIT sentences in a quiet listening environment), the MDC₉₅ of speech intelligibility ranged from 3% to 10% for speakers with MS and PD who have mildly impaired speech. These estimates are a step toward the development of a universal language with which to evaluate speech changes in a variety of patient populations.

Validating Automatic Diadochokinesis Analysis Methods Across Dysarthria Severity and Syllable Task in Amyotrophic Lateral Sclerosis

PURPOSE

Oral diadochokinesis (DDK) is a standard dysarthria assessment task. To extract automatic and semi-automatic DDK measurements, numerous DDK analysis algorithms based on acoustic signal processing are available, including amplitude based, spectral based, and hybrid. However, these algorithms have been predominantly validated in individuals with no perceptible to mild dysarthria. The behavior of these algorithms across dysarthria severity is largely unknown. Likewise, these algorithms have not been tested equally for various syllable types. The goal of this study was to evaluate the performance of five common DDK algorithms as a function of dysarthria severity, considering syllable types.

METHOD

We analyzed 282 DDK recordings of /ba/, /pa/, and /ta/ from 145 participants with amyotrophic lateral sclerosis. Recordings were stratified into mild, moderate, or severe dysarthria groups based on individual performance on the Speech Intelligibility Test. Analysis included manual and automatic estimation of the number of syllables, DDK rate, and cycle-to-cycle temporal variability (cTV). Validation metrics included Bland-Altman mixed-effects limits of agreement between manual and automatic syllable counts, recall and precision between manual and automatic syllable boundary detection, and Kendall's tau-b correlations between manual and algorithm-detected DDK rate and cTV.

RESULTS

The amplitude-based algorithm (absolute energy) yielded the strongest correlations with manual analysis across all severity groups for DDK rate (τ b = 0.7-0.84) and cTV (τ b = 0.7-0.84) and the narrowest limits of agreement (-5.92 to 7.12 syllable difference). Moreover, this algorithm also provided the highest mean recall and precision across severity groups for /ba/ and /pa/, but with significantly more variation for/ta/.

CONCLUSIONS

Algorithms based on signal energy analysis appeared to be the most robust for DDK analysis across dysarthria severity and syllable types; however, it remains prone to error against severe dysarthria and alveolar syllable context. Further development is needed to address this important issue.

Protocol for psychometric evaluation of the Amyotrophic Lateral Sclerosis - Bulbar Dysfunction Index (ALS-BDI): a prospective longitudinal study

INTRODUCTION

Early detection and tracking of bulbar dysfunction in amyotrophic lateral sclerosis (ALS) are critical for directing management of the disease. Current clinical bulbar assessment tools are lacking, while existing physiological instrumental assessments are often inaccessible and cost-prohibitive for clinical application. The goal of our research is to develop and validate a brief and reliable, clinician-administered assessment tool-the ALS-Bulbar Dysfunction Index (ALS-BDI). This publication describes the study protocol that has been established to ascertain the tools' psychometric properties.

METHODS AND ANALYSIS

The ALD-BDI's development closely follows guidelines outlined by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). Through the proposed study protocol, we expect to establish psychometric properties of both individual test items of the ALS-BDI as well as the final version of the entire tool, including test-retest and inter-rater reliability, construct validity using gold-standard assessment methods and responsiveness.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by research ethics boards at two data collection sites: Sunnybrook Health Science Centre, primary (Toronto, Canada; ID3080) and Mass General Brigham (#2013P001746, Boston, USA). Prior to participation in the study, the participants sign the informed consent in accordance with the Declaration of Helsinki. Once validated, the ALS-BDI will be disseminated to key stakeholders. Following validation, the ALS-BDI and any required training material will be implemented for clinical use in a context of a multidisciplinary ALS clinic and used as an outcome measure for clinical trials in ALS research.

The Relationship Between Single-Word Speech Severity and Intelligibility in Childhood Apraxia of Speech

PURPOSE

The purpose of this study was to investigate the association between perceived single-word speech severity and intelligibility in children with childhood apraxia of speech (CAS), with and without comorbid language impairment (LI), and to investigate the contribution of different CAS signs to perceived single-word speech severity and single-word intelligibility.

METHOD

Thirty children with CAS, 18 with comorbid LI, completed the Goldman-Fristoe Test of Articulation-Second Edition (GFTA-2). Trained judges coded children's responses for signs of CAS and percent phonemes correct. Nine listeners, blind to diagnoses, rated speech severity using a visual analog scale. Intelligibility was assessed by comparing listeners' orthographic transcriptions of children's responses to target responses.

RESULTS

Measures of speech severity (GFTA-2 standard score, number of unique CAS signs, total CAS signs, and mean severity rating) were significantly correlated with measures of intelligibility (GFTA-2 raw score, percent phonemes correct, and mean intelligibility score). Speech severity and intelligibility did not differ significantly between children with and without LI. Only consonant errors contributed significant variability to speech severity. Consonant errors and stress errors contributed significant variability to intelligibility.

CONCLUSIONS

Findings suggest that visual analog scale ratings are a valid and convenient measure of single-word speech severity and that GFTA-2 raw score is an equally convenient measure of single-word intelligibility. The result that consonant errors were by far the major contributor to single-word speech severity and intelligibility in children with CAS, with stress errors also making a small contribution to intelligibility, suggests that consonant accuracy and appropriate lexical stress should be prime therapeutic targets for these children in the context of treatment addressing motor planning/programming, self-monitoring, and self-correcting.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19119350.

Intelligibility Across a Reading Passage: The Effect of Dysarthria and Cued Speaking Styles

OBJECTIVE

Reading a passage out loud is a commonly used task in the perceptual assessment of dysarthria. The extent to which perceptual characteristics remain unchanged or stable over the time course of a passage is largely unknown. This study investigated crowdsourced visual analogue scale (VAS) judgments of intelligibility across a reading passage as a function of cued speaking styles commonly used in treatment to maximize intelligibility.

PATIENTS AND METHOD

The Hunter passage was read aloud in habitual, slow, loud, and clear speaking styles by 16 speakers with Parkinson's disease (PD), 30 speakers with multiple sclerosis (MS), and 32 control speakers. VAS judgments of intelligibility from three fragments representing the beginning, middle, and end of the reading passage were obtained from 540 crowdsourced online listeners.

RESULTS

Overall passage intelligibility was reduced for the two clinical groups relative to the control group. All speaker groups exhibited intelligibility variation across the reading passage, with trends of increased intelligibility toward the end of the reading passage. For control speakers and speakers with PD, patterns of intelligibility variation across passage reading did not differ with speaking style. For the MS group, intelligibility variation across the passage was dependent on speaking style.

CONCLUSIONS

The presence of intelligibility variation within a reading passage warrants careful selection of speech materials in research and clinical practice. Results further indicate that the crowdsourced VAS rating paradigm is useful to document intelligibility in a reading passage for different cued speaking styles commonly used in treatment for dysarthria.

"You Say Severe, I Say Mild": Toward an Empirical Classification of Dysarthria Severity

PURPOSE

The main purpose of this study was to create an empirical classification system for speech severity in patients with dysarthria secondary to amyotrophic lateral sclerosis (ALS) by exploring the reliability and validity of speech-language pathologists' (SLPs') ratings of dysarthric speech.

METHOD

Ten SLPs listened to speech samples from 52 speakers with ALS and 20 healthy control speakers. SLPs were asked to rate the speech severity of the speakers using five response options: normal, mild, moderate, severe, and profound. Four severity-surrogate measures were also calculated: SLPs transcribed the speech samples for the calculation of speech intelligibility and rated the effort it took to understand the speakers on a visual analog scale. In addition, speaking rate and intelligible speaking rate were calculated for each speaker. Intrarater and interrater reliability were calculated for each measure. We explored the validity of clinician-based severity ratings by comparing them to the severity-surrogate measures. Receiver operating characteristic (ROC) curves were conducted to create optimal cutoff points for defining dysarthria severity categories.

RESULTS

Intrarater and interrater reliability for the clinician-based severity ratings were excellent and were comparable to reliability for the severity-surrogate measures explored. Clinician severity ratings were strongly associated with all severity-surrogate measures, suggesting strong construct validity. We also provided a range of values for each severity-surrogate measure within each severity category based on the cutoff points obtained from the ROC analyses.

CONCLUSIONS

Clinician severity ratings of dysarthric speech are reliable and valid. We discuss the underlying challenges that arise when selecting a stratification measure and offer recommendations for a classification scheme when stratifying patients and research participants into speech severity categories.

Feedback and Feedforward Auditory-Motor Processes for Voice and Articulation in Parkinson's Disease

PURPOSE

Unexpected and sustained manipulations of auditory feedback during speech production result in "reflexive" and "adaptive" responses, which can shed light on feedback and feedforward auditory-motor control processes, respectively. Persons with Parkinson's disease (PwPD) have shown aberrant reflexive and adaptive responses, but responses appear to differ for control of vocal and articulatory features. However, these responses have not been examined for both voice and articulation in the same speakers and with respect to auditory acuity and functional speech outcomes (speech intelligibility and naturalness).

METHOD

Here, 28 PwPD on their typical dopaminergic medication schedule and 28 age-, sex-, and hearing-matched controls completed tasks yielding reflexive and adaptive responses as well as auditory acuity for both vocal and articulatory features.

RESULTS

No group differences were found for any measures of auditory-motor control, conflicting with prior findings in PwPD while off medication. Auditory-motor measures were also compared with listener ratings of speech function: first formant frequency acuity was related to speech intelligibility, whereas adaptive responses to vocal fundamental frequency manipulations were related to speech naturalness.

CONCLUSIONS

These results support that auditory-motor processes for both voice and articulatory features are intact for PwPD receiving medication. This work is also the first to suggest associations between measures of auditory-motor control and speech intelligibility and naturalness.

Slowing the loss of physical function in amyotrophic lateral sclerosis with edaravone: Post hoc analysis of ALSFRS-R item scores in pivotal study MCI186-19

Introduction

Phase 3 study MCI186‐19 demonstrated less loss of physical function with edaravone versus placebo, as measured by the revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS‐R) total score. A 1‐point drop in an individual ALSFRS‐R item may be clinically meaningful. We assessed ALSFRS‐R item score changes to identify clinical features protected by edaravone treatment.

Methods

Time‐to‐event analysis was used to assess the cumulative probabilities of reductions in ALSFRS‐R item scores and Amyotrophic Lateral Sclerosis Assessment Questionnaire (ALSAQ‐40) subdomain scores.

Results

Edaravone use was accompanied by: (1) delayed drop of ≥1 point in ALSFRS‐R item score for four items: salivation, walking, climbing stairs, orthopnea (unadjusted), or for two items: walking, climbing stairs (after Bonferroni correction for multiple comparisons); (2) delayed score transition from 4 or 3 at baseline to ≤2 for five items: swallowing, eating motion, walking, climbing stairs, orthopnea (unadjusted), or for one item: climbing stairs (after Bonferroni correction for multiple comparisons); and (3) delayed worsening of ALSAQ‐40 domain scores representing daily living/independence, eating and drinking (unadjusted).

Discussion

These post‐hoc analyses identified the ALSFRS‐R item scores and ALSAQ‐40 domain scores that were associated with preserved gross motor function and health‐related quality of life, respectively, after edaravone treatment. Limitations of post‐hoc analyses should be considered when interpreting these results. We recommend that clinical trials employing the ALSFRS‐R include this type of analysis as a pre‐specified secondary outcome measure.

Psychometric Properties of Rapid Word-Based Rate Measures in the Assessment of Bulbar Amyotrophic Lateral Sclerosis: Comparisons With Syllable-Based Rate Tasks

Purpose Rapid maximum performance repetition tasks have increasingly demonstrated their utility as clinimetric markers supporting diagnosis and monitoring of bulbar disease in amyotrophic lateral sclerosis (ALS). A recently developed protocol uses novel real-word repetitions instead of traditional nonword/syllable sequences in hopes of improving sensitivity to motor speech impairments by adding a phonological target constraint that would activate a greater expanse of the motor speech neuroanatomy. This study established the psychometric properties of this novel clinimetric protocol in its assessment of bulbar ALS and compared performance to traditional syllable sequence dysdiadochokinetic (DDK) tasks. Specific objectives were to (a) compare rates between controls and speakers with symptomatic versus presymptomatic bulbar disease, (b) characterize their discriminatory ability in detecting presymptomatic bulbar disease compared to healthy speech, (c) determine their articulatory movement underpinnings, and (d) establish within-individual longitudinal changes. Method DDK and novel tongue ("ticker"-TAR) and labial ("pepper"-LAR) articulatory rates were compared between n = 18 speakers with presymptomatic bulbar disease, n = 10 speakers with symptomatic bulbar disease, and n = 13 healthy controls. Bulbar disease groups were determined by a previously validated speaking rate cutoff. Discriminatory ability was determined using receiver operating characteristic analysis. Within-individual change over time was characterized in a subset of 16 participants with available longitudinal data using linear mixed-effects models. Real-time articulatory movements of the tongue front, tongue dorsum, jaw, and lips were captured using 3-D electromagnetic articulography; effects of movement displacement and speed on clinimetric rates were determined using stepwise linear regressions. Results All clinimetric rates (traditional DDK tasks and novel tasks) were reduced in speakers with symptomatic bulbar disease; only TAR was reduced in speakers with presymptomatic bulbar disease and was able to detect this group with an excellent discrimination ability (area under the curve = 0.83). Kinematic analyses revealed associations with expected articulators, greater motor complexity, and differential articulatory patterns for the novel real-word repetitions than their DDK counterparts. Only LAR significantly declined longitudinally over the disease course. Conclusion Novel real-word clinimetric rate tasks evaluating tongue and labial articulatory dysfunction are valid and effective markers for early detection and tracking of bulbar disease in ALS.

Psychometric Analysis of an Ecological Vocal Effort Scale in Individuals With and Without Vocal Hyperfunction During Activities of Daily Living

Objective The purpose of this study was to examine the psychometric properties of an ecological vocal effort scale linked to a voicing task. Method Thirty-eight patients with nodules, 18 patients with muscle tension dysphonia, and 45 vocally healthy control individuals participated in a week of ambulatory voice monitoring. A global vocal status question was asked hourly throughout the day. Participants produced a vowel-consonant-vowel syllable string and rated the vocal effort needed to produce the task on a visual analog scale. Test-retest reliability was calculated for a subset using the intraclass correlation coefficient, ICC(A, 1). Construct validity was assessed by (a) comparing the weeklong vocal effort ratings between the patient and control groups and (b) comparing weeklong vocal effort ratings before and after voice rehabilitation in a subset of 25 patients. Cohen's d, the standard error of measurement (SEM), and the minimal detectable change (MDC) assessed sensitivity. The minimal clinically important difference (MCID) assessed responsiveness. Results Test-retest reliability was excellent, ICC(A, 1) = .96. Weeklong mean effort was statistically higher in the patients than in controls (d = 1.62) and lower after voice rehabilitation (d = 1.75), supporting construct validity and sensitivity. SEM was 4.14, MDC was 11.47, and MCID was 9.74. Since the MCID was within the error of the measure, we must rely upon the MDC to detect real changes in ecological vocal effort. Conclusion The ecological vocal effort scale offers a reliable, valid, and sensitive method of monitoring vocal effort changes during the daily life of individuals with and without vocal hyperfunction.

Minimal Clinically Important Difference and Patient Acceptable Symptom State for the Pittsburgh Sleep Quality Index in Patients Who Underwent Rotator Cuff Tear Repair

The Pittsburgh Sleep Quality Index (PSQI) is a valid patient-reported outcome measure developed to assess sleep quality and disturbances in clinical populations. This study aimed to calculate the minimum clinically important difference (MCID) and the patient acceptable symptom state (PASS) for the PSQI in patients who underwent rotator cuff repair (RCR). Preoperative and six-month postoperative follow-up questionnaires were completed by 50 patients (25 males and 25 females, mean age 58.7 ± 11.1 years). The MCID of the PSQI was calculated using distribution-based and anchor methods. To calculate the PSQI’s PASS, the 75th percentile approach and the receiver operating characteristic (ROC) curve were used. The MCID from preoperative to 6 months postoperative follow-up is 4.4. Patients who improved their PSQI score of 4.4 from baseline to 6 months follow-up had a clinically significant increase in their health status. The PASS is 5.5 for PSQI; therefore, a value of PSQI at least 5.5 at six months follow-up indicates that the symptom state can be considered acceptable by most patients.

A Perceptual Learning Approach for Dysarthria Remediation: An Updated Review

Purpose Early studies of perceptual learning of dysarthric speech, those summarized in Borrie, McAuliffe, and Liss (2012), yielded preliminary evidence that listeners could learn to better understand the speech of a person with dysarthria, revealing a potentially promising avenue for future intelligibility interventions. Since then, a programmatic body of research grounded in models of perceptual processing has unfolded. The current review provides an updated account of the state of the evidence in this area and offers direction for moving this work toward clinical implementation. Method The studies that have investigated perceptual learning of dysarthric speech (N = 24) are summarized and synthesized first according to the proposed learning source and then by highlighting the parameters that appear to mediate learning, culminating with additional learning outcomes. Results The recent literature has established strong empirical evidence of intelligibility improvements following familiarization with dysarthric speech and a theoretical account of the mechanisms that facilitate improved processing of the neurologically degraded acoustic signal. Conclusions There are no existing intelligibility interventions for individuals with dysarthria who cannot behaviorally modify their speech. However, there is now robust support for the development of an approach that shifts the weight of behavioral change from speaker to listener, exploiting perceptual learning to ease the intelligibility burden of dysarthria. To move this work from bench to bedside, recommendations for translational studies that establish best practices and candidacy for listener-targeted dysarthria remediation, perceptual training, are provided.

Investigating Acoustic Correlates of Intelligibility Gains and Losses During Slowed Speech: A Hybridization Approach

Purpose This exploratory study sought to identify acoustic variables explaining rate-related variation in intelligibility for speakers with dysarthria secondary to multiple sclerosis. Method Seven speakers with dysarthria due to multiple sclerosis produced the same set of Harvard sentences at habitual and slow rates. Speakers were selected from a larger corpus on the basis of rate-related intelligibility characteristics. Four speakers demonstrated improved intelligibility and three speakers demonstrated reduced intelligibility when rate was slowed. A speech analysis resynthesis paradigm termed hybridization was used to create stimuli in which segmental (i.e., short-term spectral) and suprasegmental variables (i.e., sentence-level fundamental frequency, energy characteristics, and duration) of sentences produced at the slow rate were donated individually or in combination to habitually produced sentences. Online crowdsourced orthographic transcription was used to quantify intelligibility for six hybridized sentence types and the original habitual and slow productions. Results Sentence duration alone was not a contributing factor to improved intelligibility associated with slowed rate. Speakers whose intelligibility improved with slowed rate showed higher intelligibility scores for duration spectrum hybrids and energy hybrids compared to the original habitual rate sentences, suggesting these acoustic cues contributed to improved intelligibility for sentences produced with a slowed rate. Energy contour characteristics were also found to play a role in intelligibility losses for speakers with decreased intelligibility at slowed rate. The relative contribution of speech acoustic variables to intelligibility gains and losses varied considerably between speakers. Conclusions Hybridization can be used to identify acoustic correlates of intelligibility variation associated with slowed rate. This approach has further elucidated speaker-specific and individualized speech production adjustments when slowing rate.

Speech Treatment Effects on Narrative Intelligibility in French-Speaking Children With Dysarthria

Purpose This study examined the effects of Speech Intelligibility Treatment (SIT) on intelligibility and naturalness of narrative speech produced by francophone children with dysarthria due to cerebral palsy. Method Ten francophone children with dysarthria were randomized to one of two treatments, SIT or Hand-Arm Bimanual Intensive Therapy Including Lower Extremities, a physical therapy (PT) treatment. Both treatments were conducted in a camp setting and were comparable in dosage. The children were recorded pre- and posttreatment producing a story narrative. Intelligibility was measured by means of 60 blinded listeners' orthographic transcription accuracy (percentage of words transcribed correctly). The listeners also rated the children's naturalness on a visual analogue scale. Results A significant pre- to posttreatment increase in intelligibility was found for the SIT group, but not for the PT group, with great individual variability observed among the children. No significant changes were found for naturalness ratings or sound pressure level in the SIT group or the PT group posttreatment. Articulation rate increased in both treatment groups, although not differentially across treatments. Conclusions Findings from this first treatment study on intelligibility in francophone children with dysarthria suggest that SIT shows promise for increasing narrative intelligibility in this population. Acoustic contributors to the increased intelligibility remain to be explored further. Supplemental Material https://doi.org/10.23641/asha.14161943.

Two Distinct Clinical Phenotypes of Bulbar Motor Impairment in Amyotrophic Lateral Sclerosis

Objective: Understanding clinical variants of motor neuron diseases such as amyotrophic lateral sclerosis (ALS) is critical for discovering disease mechanisms and across-patient differences in therapeutic response. The current work describes two clinical subgroups of patients with ALS that, despite similar levels of bulbar motor involvement, have disparate clinical and functional speech presentations.

Methods: Participants included 47 healthy control speakers and 126 speakers with ALS. Participants with ALS were stratified into three clinical subgroups (i.e., bulbar asymptomatic, bulbar symptomatic high speech function, and bulbar symptomatic low speech function) based on clinical metrics of bulbar motor impairment. Acoustic and lip kinematic analytics were derived from each participant's recordings of reading samples and a rapid syllable repetition task. Group differences were reported on clinical scales of ALS and bulbar motor severity and on multiple speech measures.

Results: The high and low speech-function subgroups were found to be similar on many of the dependent measures explored. However, these two groups were differentiated on the basis of an acoustic measure used as a proxy for tongue movement.

Conclusion: This study supports the hypothesis that high and low speech-function subgroups do not differ solely in overall severity, but rather, constitute two distinct bulbar motor phenotypes. The findings suggest that the low speech-function group exhibited more global involvement of the bulbar muscles than the high speech-function group that had relatively intact lingual function. This work has implications for clinical measures used to grade bulbar motor involvement, suggesting that a single bulbar measure is inadequate for capturing differences among phenotypes.

A Clinical Advantage: Experience Informs Recognition and Adaptation to a Novel Talker With Dysarthria

Purpose Perceptual training paradigms, which leverage the mechanism of perceptual learning, show that naïve listeners, those with no prior experience with dysarthria, benefit from explicit familiarization with a talker with dysarthria. It is theorized that familiarization affords listeners an opportunity to acquire distributional knowledge of the degraded speech signal. Here, we extend investigations to clinically experienced listeners, speech-language pathologists (SLPs), and advance models of listener recognition and adaptation to dysarthric speech. Method Forty-seven SLPs completed a standard three-phase perceptual training protocol (pretest, familiarization, and posttest) with a novel talker with dysarthria. Intelligibility scores were compared with historical data from naïve listeners. Potential relationships between intelligibility scores and characteristics of clinical experience were examined. Results Intelligibility scores of SLPs improved by an average of 19% from pretest to posttest. This intelligibility improvement was lower than naïve listeners, although the difference was small. Moreover, clinical characteristics related to level of dysarthria experience (e.g., percent of caseload composed of dysarthria) predicted pretest/initial intelligibility. No predictive relationships between clinical characteristics and intelligibility improvement were revealed. Conclusions As a group, SLPs benefitted from perceptual training, suggesting that, despite prior experience, the opportunity to acquire knowledge of talker-specific cue distributions is crucial for optimal adaptation. However, SLPs with greater dysarthria experience were better at initially understanding the talker with dysarthria. This suggests that, through regular interaction with individuals with dysarthria, clinicians acquire knowledge of the cue distributions of dysarthric speech more generally and can generalize this group-specific knowledge to aid in understanding other talkers with dysarthria. Consistent with theoretical models of perceptual learning, both talker- and group-specific knowledge informed recognition and adaptation to dysarthric speech.

Patterns of Misidentified Vowels in Individuals With Dysarthria Secondary to Amyotrophic Lateral Sclerosis

Purpose The current study examines the pattern of misidentified vowels produced by individuals with dysarthria secondary to amyotrophic lateral sclerosis (ALS). Method Twenty-three individuals with ALS and 22 typical individuals produced 10 monophthongs in an /h/-vowel-/d/ context. One hundred thirty-five listeners completed a forced-choice vowel identification test. Misidentified vowels were examined in terms of the target vowel categories (front-back; low-mid-high) and the direction of misidentification (the directional pattern when the target vowel was misidentified, e.g., misidentification "to a lower vowel"). In addition, acoustic predictors of vowel misidentifications were tested based on log first formant (F1), log second formant, log F1 vowel inherent spectral change, log second formant vowel inherent spectral change, and vowel duration. Results First, high and mid vowels were more frequently misidentified than low vowels for all speaker groups. Second, front and back vowels were misidentified at a similar rate for both the Mild and Severe groups, whereas back vowels were more frequently misidentified than front vowels in typical individuals. Regarding the direction of vowel misidentification, vowel errors were mostly made within the same backness (front-back) category for all groups. In addition, more errors were found toward a lower vowel category than toward a higher vowel category in the Severe group, but not in the Mild group. Overall, log F1 difference was identified as a consistent acoustic predictor of the main vowel misidentification pattern. Conclusion Frequent misidentifications in the vowel height dimension and the acoustic predictor, F1, suggest that limited tongue height control is the major articulatory dysfunction in individuals with ALS. Clinical implications regarding this finding are discussed.

When Additional Training Isn't Enough: Further Evidence That Unpredictable Speech Inhibits Adaptation

Purpose Robust improvements in intelligibility following familiarization, a listener-targeted perceptual training paradigm, have been revealed for talkers diagnosed with spastic, ataxic, and hypokinetic dysarthria but not for talkers with hyperkinetic dysarthria. While the theoretical explanation for the lack of intelligibility improvement following training with hyperkinetic talkers is that there is insufficient distributional regularity in the speech signals to support perceptual adaptation, it could simply be that the standard training protocol was inadequate to facilitate learning of the unpredictable talker. In a pair of experiments, we addressed this possible alternate explanation by modifying the levels of exposure and feedback provided by the perceptual training protocol to offer listeners a more robust training experience. Method In Experiment 1, we examined the exposure modifications, testing whether perceptual adaptation to an unpredictable talker with hyperkinetic dysarthria could be achieved with greater or more diverse exposure to dysarthric speech during the training phase. In Experiment 2, we examined feedback modifications, testing whether perceptual adaptation to the unpredictable talker could be achieved with the addition of internally generated somatosensory feedback, via vocal imitation, during the training phase. Results Neither task modification led to improved intelligibility of the unpredictable talker with hyperkinetic dysarthria. Furthermore, listeners who completed the vocal imitation task demonstrated significantly reduced intelligibility at posttest. Conclusion Together, the results from Experiments 1 and 2 replicate and extend findings from our previous work, suggesting perceptual adaptation is inhibited for talkers whose speech is largely characterized by unpredictable degradations. Collectively, these results underscore the importance of integrating signal predictability into theoretical models of perceptual learning.

Measuring lumbar back motion during functional activities using a portable strain gauge sensor-based system: A comparative evaluation and reliability study

Quantifying lumbar back motion during functional activities in real-life environments may contribute to a better understanding of common pathologies such as spinal disorders. The current study therefore aimed at the comparative evaluation of the Epionics SPINE system, a portable device for measuring sagittal lumbar back motion during functional activities. Twenty healthy participants were therefore evaluated with the Epionics SPINE and a Vicon motion capture system in two identical separate research visits. They performed the following activities: standing, sitting, chair rising, box lifting, walking, running and a counter movement jump (CMJ). Lumbar lordosis angles were extracted as continuous values as well as average and range of motion (ROM) parameters. Agreement between the systems was evaluated using Bland-Altman analyses, whereas within- and between-session reliability were assessed using intraclass correlation coefficients (ICC) and minimal detectable changes (MDC). The analysis showed excellent agreement between the systems for chair rising, box lifting and CMJ with a systematic underestimation of lumbar lordosis angles during walking and running. Reliability was moderate to high for all continuous and discrete parameters (ICC ≥ 0.62), except for ROM during running (ICC = 0.29). MDC values were generally below 15°, except for CMJ (peak values up to 20° within and 25° between the sessions). The Epionics SPINE system performed similarly to a Vicon motion capture system for measuring lumbar lordosis angles during functional activities and showed high consistency within and between measurement sessions. These findings can serve researchers and clinicians as a bench mark for future investigations using the system in populations with spinal pathologies.

Reliability and validity of speech & pause measures during passage reading in ALS

Objective: The use of speech measures is becoming a common practice in the assessment of bulbar disease progression in amyotrophic lateral sclerosis (ALS). This study aimed to establish psychometric properties (e.g. reliability, validity, sensitivity, specificity) of speech and pause timing measures during a standardized passage. Methods: A large number of passage recordings (ALS N = 775; Neurotypical controls N = 323) was analyzed using a semi-automatic method (Speech and Pause Analysis, SPA). Results: The results revealed acceptable reliability of the speech and pause measures across repeated recording by the control participants. Strong construct validity was established via significant group differences between patients and controls and correlation statistics with clinical measures of overall ALS and bulbar disease severity. Speaking rate, pause events, and mean pause duration were able to detect ALS participants at the presymptomatic stage of bulbar disease with a good discrimination ability (AUC 0.81). Conclusions: Based on the current psychometric evaluation, performing passage recording and speech and pause timing analysis was deemed useful for detecting early and progressive changes associated with bulbar ALS.

Shorter Sentence Length Maximizes Intelligibility and Speech Motor Performance in Persons With Dysarthria Due to Amyotrophic Lateral Sclerosis

Purpose The purpose of this study was to investigate the effect of sentence length on intelligibility and measures of speech motor performance in persons with amyotrophic lateral sclerosis (ALS) and to determine how these effects were influenced by dysarthria severity levels. Method One hundred thirty-one persons with ALS were included in this study, stratified into 4 dysarthria severity groups. All participants produced sentences from 5 to 15 words in length. Intelligibility, speaking rate, and measures of speech pausing behavior (i.e., total speech duration, total pause duration, and mean speech event duration) were measured for each sentence. Linear mixed-effects models were used to determine the effect of sentence length on speech measures for speakers at different dysarthria severity levels. Results Results showed that speech intelligibility significantly declined at longer sentence lengths only for the speakers with ALS who had more advanced dysarthria symptoms; however, speakers with mild-to-severe dysarthria showed significant declines in speaking rate and speech pausing behavior at longer sentence lengths. Conclusions Findings suggest that producing shorter sentences may help maximize intelligibility for speakers with moderate-to-severe dysarthria secondary to ALS and may be a beneficial compensatory strategy for preserving motor effort for all speakers with dysarthria secondary to ALS.

Clinical Measures of Bulbar Dysfunction in ALS

Bulbar impairment represents a hallmark feature of Amyotrophic Lateral Sclerosis (ALS) that significantly impacts survival and quality of life. Speech and swallowing dysfunction are key contributors to the clinical heterogeneity of ALS and require well-timed and carefully coordinated interventions. The accurate clinical, radiological and electrophysiological assessment of bulbar dysfunction in ALS is one of the most multidisciplinary aspects of ALS care, requiring expert input from speech-language pathologists (SLPs), neurologists, otolaryngologists, augmentative alternative communication (AAC) specialists, dieticians, and electrophysiologists—each with their own evaluation strategies and assessment tools. The need to systematically evaluate the comparative advantages and drawbacks of various bulbar assessment instruments and to develop integrated assessment protocols is increasingly recognized. In this review, we provide a comprehensive appraisal of the most commonly utilized clinical tools for assessing and monitoring bulbar dysfunction in ALS based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) evaluation framework. Despite a plethora of assessment tools, considerable geographical differences exist in bulbar assessment practices and individual instruments exhibit considerable limitations. The gaps identified in the literature offer unique opportunities for the optimization of existing and development of new tools both for clinical and research applications. The multicenter validation and standardization of these instruments will be essential for guideline development and best practice recommendations.